Ph 09 444 4527
for a healthier future
Health Assessment Questionnaire
Call
09 444 4527
for an appointment
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Please complete this form at least 48 hours before your first appointment to help us gain an understanding of how we can help.
Personal Details
Select One
*
Mr
Mrs
Miss
Ms
Dr
First Name
*
Last Name
*
Date of Birth
*
Contact Details
Street Address
*
Surburb
City
*
Post Code
*
Country
*
Phone Number
*
Mobile Number
*
Email
*
Medical Details
Reason for attending clinic?
*
Do you have any other existing medical conditions?
*
If so please provide details
Medications
What medications are you taking?
*
Please list any medications, that you're taking.
What supplements/herbs are you taking?
*
Have you tried any other therapies for this condition?
*
Do you have any known allergies? Please list
*
Do any of your other family members have similar health conditions?
*
If so please provide details
Digestive Health
Please indicate if you experience any of the following on a scale of 1 – 4 with
1 being never,
2 being occasionally,
3 being frequently and
4 being daily
Diarrhoea
*
1
2
3
4
Constipation
*
1
2
3
4
Alternating constipation and diarrhoea
*
1
2
3
4
Feelings of bloating
*
1
2
3
4
Craving sweet foods in the afternoon
*
1
2
3
4
General low energy
*
1
2
3
4
Low energy in the afternoon only
*
1
2
3
4
Please bring any recent medical test results with you
Attached to this questionnaire is a 1 week food diary. Please DOWNLOAD it and bring it with you to your consultation. Please complete it honestly using a typical week.
NO judgements are being made but it is useful to indicate possible nutrient deficiencies.
Thank you for completing this form and we look forward to seeing you at your appointment.
food_diary.pdf
File Size:
56 kb
File Type:
pdf
Download File